Provider Demographics
NPI:1629182217
Name:LEBEDEFF, DIANE S (DPM)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:S
Last Name:LEBEDEFF
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-4501
Mailing Address - Country:US
Mailing Address - Phone:443-992-1275
Mailing Address - Fax:410-647-5576
Practice Address - Street 1:273 PENINSULA FARM RD STE E
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-1012
Practice Address - Country:US
Practice Address - Phone:410-647-4534
Practice Address - Fax:410-647-8997
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01106213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD113M018FOtherMC
MD219158000Medicaid
MD219158000Medicaid